Creating a Tic Management Environment for Your Child

Even though tics are a neurological problem, they are heavily influenced by things that happen on a daily basis. You can probably tell when your child’s tics are going to get worse or better based on what he or she is doing or where he is. From our time working with children with TS, we have noticed a number of things that make tics worse than they need to be and have made a set of principles you can follow to help your child with his tics.

PRINCIPLE 1: Do NOT react to your child’s tics

Reason: Tics like attention. Making comments about tics as they happen, asking the child to stop, laughing about tics, comforting a child when he has difficult tics, or even teasing a child about tics are all forms of attention that tics feed on. It is important to create a world for the child in which there are no reactions to tics. It should be as if they aren’t happening.

If you find yourself wanting to comfort your child after he does a tic, say very little. Instead, wait until he’s not ticcing as much and ask him how he’s doing.

If your children are teasing their brother/sister because of the tics, be clear and firm with them that they must not do this and discipline them in a way that will support this request.

If your child’s peers or relatives make comments about the tics, please pull them aside and ask them not to react to the tics.

Sometimes tics can be funny, but don’t laugh when they happen. Pretend as if they did not occur.

If your child says an inappropriate word as a vocal tic, do not punish or react to what the word or phrase was. Instead, make it an expectation that your child apologize to you and explain to you that it was a tic.

Example 1: Mark is a 9 year old boy who has a very noticeable shoulder-shrugging tic. A number of children in the school call Mark “jerky” and tease him about his ticcing. As part of creating a tic-neutral environment, Mark’s parents should approach the school personnel (i.e., guidance counselor, teacher, or principal) and ask them to come up with a plan to stop the reactions of the bullying students.

Example 2. Mary has a very noticeable neck jerking tic that results her neck hurting. Because Mary’s parents are concerned for their daughter and feel bad about the pain she experiences, they rub her neck and tell her that it will be alright whenever she starts to tic. As part of creating a tic-neutral environment, Mary’s parents should stop giving Mary neck-rubs when she tics and should stop discussing the tics with her as they occur. Instead, Mary’s parents should simply prompt Mary to use the competing response exercises taught in treatment. At a different time, when Mary is not doing or has not just done the neck jerking tic, Mary can be given a neck rub and the parents can reassure Mary that she will be ok.

Example 3. Paul has a vocal tic that is uncontrollable. When he sees someone who is overweight Paul yells out “fat boy.” Paul’s parents know that this is something he can’t control, so when the teacher’s in Paul’s class called and told them that Paul was calling a child in his class “fat boy,” they explained to the teacher it was Paul’s TS and that the school would just have to accommodate Paul’s condition. As part of creating a tic-neutral environment, the parents were correct that Paul cannot control his vocal tic. However, they should have worked with Paul and his therapist to develop a plan that would minimize the possibility that other children would hear the tic. Perhaps a strategy could have been put in place allowing Paul to muffle the sound when he feels it coming or restructuring the classroom seating arrangement so Paul would be less likely to encounter the targeted child. Likewise, they should have come up with a plan that involves Paul explaining to the whole class why the tic occurs and should have held Paul to the expectation that he apologize to the targeted child every time the tic happens.

PRINCIPLE 2: Express any frustrations with your child’s condition only when your child is not near you.

Reason: Having a child with tics can be tough. As a parent you want to help your child when they’re suffering, and you may even feel it’s your fault. Parents of children with tics often go through many emotions, guilt, sadness, disappointment, frustration, and even anger. This is natural, but it is important that your child doesn’t see this in your eyes, or hear it in your voice. If he does, he will likely feel very bad and feeling bad can make the tics even worse.

When you get frustrated with your child, calmly leave the room until you think you can interact in a calm manner.

When you and your spouse disagree on how to handle the tics, go to another room, out of the child’s sight and range of hearing. Calmly talk through your differences until you come to an agreement.

When family questions you or your child’s tics, explain to them in a calm manner that tics are not intentional, but that there are things that both you and your child are learning to do that may help manage the symptoms. Your child should feel supported in his efforts to manage the symptoms and you should view this as working together on a team.

Remember that this should never become a battle with your child over his or her tics. You are there to support your child’s efforts at managing his tics. If you feel like you’re doing all the work, then you probably need to back off and discuss it in the next session.

Example 1. Marty’s mother has taken the brunt of Marty’s condition. She sees the stares of strangers and family members. She hurts when Marty cries at night because he can’t get to sleep. She’s often on the receiving end of Marty’s tantrums. One night at the dinner table, after a particularly bad day that involved a call from school, Marty’s mother had reached a boiling point and started explaining to her husband that she “just can’t take it anymore.” To create a tic-neutral environment, Marty’s mother should have waited until after dinner and after Marty had gone to bed to have the discussion with her husband. Likewise, Marty’s mother may want to consider seeking counseling to help her deal with the struggles of having a son with TS.

Example 2. Jane’s parents have been seeing a therapist who has told them to stop reacting to Jane’s loud vocal tics. Jane’s mother has gone to every session and is working hard at creating a tic management environment, but Jane’s father thinks that Jane does the sounds to irritate him. This frequently creates clear disagreements that the parents often have right in front of Jane. In creating a tic management environment, the parents should not have these disagreements in front of Jane. Rather, when Jane goes to bed, Jane’s mother and father should discuss their disagreements, and Jane’s father should be encouraged to come to the therapy sessions in hopes that the therapist can bring him on-board.

Example 3. Zach has had tics for 5 years, and is going through behavior therapy. However, his mother is getting frustrated because she feels like she has to badger him into doing his competing response exercises. Every time Zach is prompted to do his exercise, he refuses and his mother has to beg and cajole him into doing them. To create a tic management environment, Zach’s mother should first explain the situation to Zach’s therapist. Next, she should remember that her job is only to prompt him once. It is up to Zach as to whether or not he will do the exercise.

PRINCIPLE 3: Interact with your child about his or her strengths rather than being the “tic police”

Reason: Frequently checking in with your child about his or her tics or asking your child to stop your tics is like asking someone who is paralyzed if they can feel anything today or asking them to get up and walk. It’s simply not possible in the long run, and will ultimately frustrate the child and make him feel bad about himself. The child needs to know that the most important part about him is not whether or not he tics. He or she should get the message loud and clear that he or she is loved regardless of whether he has no tics or a thousand tics. That said, in this treatment, we do ask your child to learn tic-management skills that you will remind him to use, but this is different than telling him to stop his tics.

Example 1. Silas comes home from school every day and the question is always the same. “Did you have a lot of tics today?” his mother asks. They then go on to talk for 10 minutes about the tics and the conversation ends with his mother being happy (if he had few tics) or him getting scolded or pitied (if he had a lot of tics). In any case, the conversation ends, and Silas goes downstairs to watch TV. In creating a tic-neutral environment, Silas’ mother should try to refrain from being a “tic accountant” and instead have after school conversations that focus on what Silas did well in school during that day or about some other strength Silas has.

Example 2. Quinn often has tics when it is most quiet. His parents have gotten into the habit of stressing how important it is to stop his tics. Frequently, they tell him to “stop ticcing” and it ultimately makes the tics worse. To create a tic management environment, his parents should instead ignore the tics and when they are entering situations where Quinn’s tics are likely to get worse, they should review the efforts he can make to successfully manage his tics, and encourage him to use his exercises when his tics get worse. The difference here is that what the parents were originally doing was telling him to stop something he couldn’t (i.e., he was always going to fail a request to “stop ticcing”, but in the tic-management environment, they were telling him to do something that he could succeed in doing (i.e., he can always try to manage and be successful by simply trying).

PRINCIPLE 4: Expect as much from your child as you would if he did not have tics. Tics should never be a reason to lower expectations for a child.

Reason: Some things are harder to do when you have tics. Homework can get harder, doing activities in class can get harder. Often, parents or teachers see this and want to make it easier for the child so they let them out of the task. Sometimes it’s just easier to do things yourself because it takes your child with tics longer to do it or because he struggles or complains while doing it. Unfortunately, when a child is allowed to avoid doing something or is allowed to leave a difficult situation because of tics, it can encourage the tics. It is important to teach the child that the tics can’t be an excuse for failing to do something.

If your child is ticcing a lot while doing homework, encourage him to use his tic management skills (i.e., exercises) at that time.

If your child’s tics happen frequently during homework, establish a fixed schedule of short breaks (i.e., 1 minute break for every 15 minutes of homework), during which time, your child can get up and stretch or walk around.

If your teacher needs to send your child out of the classroom because of tics, make sure the child is asked to take any work that needs to be completed with him or her.

Try not to let your child avoid going places because of the tics. Instead, remind him or her to use the tic management skills and both you and your child should try to educate the people that will be at the place you’re going about the tics.

Example 1. Bryan is a poor reader and has loud vocal tics that are much worse when he gets nervous. Bryan’s teacher knows this, and when he has to read aloud in class, he often has a burst of tics. When they get too bad, Bryan’s teacher tells Bryan to take a break and go to the guidance counselor’s office until his tics go down. To create a tic management environment, instead of sending Bryan out of the classroom, the teacher should first modify the classroom so there is less of a chance that Bryan’s tics will get worse. For example, she could make him read to himself rather than aloud and then ask questions of Bryan to insure that he had comprehended the material. If the tics did get too disruptive to the other students, the teacher should consider sending Bryan out of the room, but this should not be framed as a punitive action, and Bryan should be expected to take his work with him and get the work done while he is away from the classroom.

Example 2. Micky and her family have not been to a restaurant in 3 years because Micky has very noticeable tics and she and her parents are very self-conscious about them. To create a tic-neutral environment, Micky and her parents should make a point of scheduling nights out to eat. Before doing so, they should remind and rehearse all of Micky’s tic management strategies (i.e., relaxation training, competing responses) and should schedule a time at the restaurant when it is less likely to be crowded. In addition, Micky and her parents should let the waitstaff know about Micky’s condition, and Micky and her parents should consider telling people around Micky’s table that Micky has TS.

PRINCIPLE 5. Keep Your Child Mentally and Physically Busy

Reason: Tics often get worse when there is nothing to do. Physical activities or engaging mental activities are often a tic’s greatest enemy. Because of that, you should make sure that your child has focused down time and gets plenty of physical activity. It is important for a child to get down time, but this time should be filled with activities that that require both focus and concentration. It’s also important to make sure your child has plenty of physical activity during the day.

During down time, make sure you have different quiet activities that involve doing other things your child can get engaged with (doing puzzles, artwork, etc).

In periods of sitting still, try to schedule a break every 10-15 minutes during which your child can get up and move around.

Try to schedule physical activities for your child to do so there are not long periods of down time on the weekends or weeknights.

PRINCIPLE 6. Have an established bedtime routine

Reason: Tics usually get worse when things are unpredictable. Establishing a predictable bedtime routine can be one of the more important things you can do because it gives the child a structure that he or she can count on to end every day.

PRINCIPLE 7. Make sure your child gets enough sleep

Reason: You probably have noticed that tics get worse when kids get tired. The parts of the brain that create tics can get tired too, and when this happens, the tics will flare up.

PRINCIPLE 8. Remind your child to relax when he’s stressed

Reason: You may have noticed that your child’s tics get worse when he is upset, stressed, or anxious. We’re going to teach your child how to do a style of breathing that will make him more relaxed. When you notice your child getting nervous or upset, it is a good idea to bring her to a quiet place and let him practice his relaxed breathing.

Together we discover. Together we teach.Together we care for our patients and our communities.Together we create unstoppable momentum.